Pharmaceutical Needs Assessment 2018 2021 - Warrington Health and Wellbeing Board - Warrington ...

 
Pharmaceutical Needs Assessment 2018 2021 - Warrington Health and Wellbeing Board - Warrington ...
Warrington
   Health and Wellbeing Board

Pharmaceutical Needs
    Assessment

      2018 - 2021

                                -1-
Pharmaceutical Needs Assessment 2018 2021 - Warrington Health and Wellbeing Board - Warrington ...
Developed by:
Warrington Borough Council Public Health Knowledge and Intelligence Team
in partnership with members of the PNA Working Group

Issue Date: 1st April 2018

Review Date: Supplementary Statements when necessary. Formal review by April 2021

Version Control

Version    Status   Description of amendments                                          Date of
                                                                                    publication or
                                                                                     amendment
1.0       Draft     Draft to Warrington Health and Wellbeing Board, to be             09/10/17
                    approved for public consultation
1.1       Draft     Draft for statutory public consultation                           10/10/17
                    (minor amendments to v1.0)
2.1       Draft     Post‐consultation draft to Warrington Health and Wellbeing        16/01/18
                    Board for approval for final publication.
                    Amendments made to main document due to responses
                    received from public consultation.
                    Appendix 6 added to list these responses along with the
                    amendments made as a result.
                    Appendix 7 added to list amendments resulting from closure of
                    one pharmacy during consultation period, and other minor
                    amendments
2.2       Final     Approved by Warrington Health and Wellbeing Board on               1/4/18
                    25/1/18 for final publication on 1/4/18.

                                                                                             -3-
Executive Summary
The production and publication of a Pharmaceutical Needs Assessment (PNA) became a statutory
requirement in the Health Act 2009. Following the abolition of Primary Care Trusts in 2013, this
statutory responsibility was passed to Health and Wellbeing Boards by virtue of the National Health
Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013, which came into
force on 1st April 2013.

Pharmaceutical services are provided across primary, secondary and community care settings.
Pharmacy has much more to offer than the safe and effective dispensing of medicines. It is
increasingly expanding its provision of additional clinical services, becoming a valuable force in
improving health and wellbeing and reducing health inequalities.

The commissioning of effective and appropriate pharmaceutical services is as important as the
commissioning of other primary healthcare services. However, this area of commissioning is
complex, with a number of distinctive features that are unique to pharmacy. Primary care
commissioners will require robust and up-to-date information regarding current pharmaceutical
service provision if they are to maximise the opportunities that pharmacies can offer to help
improve the health of the local population. A PNA provides the localised information needed to
support them in that role.

The assessment made in this PNA concludes that across Warrington as a whole there are currently
no pharmaceutical needs that cannot be met by existing contractors. It is recognised however that
provision does vary between localities and there is substantial housing developed planned. Regular
review is therefore recommended.

   •   As at February 2018, Warrington has 42 community pharmacy contractors (one of which is
       also contracted by NHS England to provide the Local Pharmaceutical Services (LPS) ‘Out of
       Hours’ service). There are also two Distance Selling (internet) pharmacy contractors. All
       responded to a survey undertaken to gather information for this PNA on the services they
       offer and their opening hours.

   •   The population of Warrington Local Authority area as a whole is adequately served in terms
       of the range, availability and accessibility of community pharmaceutical services.
       Warrington has approximately one pharmacy for every 4,970 residents. The England
       average is approximately one pharmacy per 4,600 residents.

   •   The number of pharmacies per head of population varies across the borough. Geographical
       mapping of provision highlights that more services are delivered in the most densely
       populated areas of the borough. In the main, these are also the areas with the highest levels
       of socio-economic deprivation and ill-health. Service delivery must continue to be in line
       with both population growth and deprivation.

   •   Warrington is a growing town, and there is planned and proposed development in all
       Warrington neighbourhood areas over the next five years. It is anticipated that capacity
       within existing services should be able to support the pharmaceutical needs of future
       populations overall. However, it is important that provision continues to be in line with

                                                                                               -4-
population growth, levels of need, and service configuration across different areas of the
      borough. Regular review will therefore be needed and for NHSE to work, in the first
      instance, with existing contractors to secure appropriate distribution and accessibility of
      services wherever possible.

  •   Across Warrington as a whole, there is adequate access to ‘out of hours’ pharmacy services,
      in that there are 5 ‘100 hour contract’ pharmacies, 3 of which are in the central areas of
      Warrington, one in South Warrington and one in West Warrington. The East of the borough
      has no pharmacy delivering a 100 hour contract; it does have good coverage on Saturday,
      with all 6 pharmacies opening for at least half a day, although none currently open on
      Sunday. The vast majority of pharmacies open in excess of their core contract hours. There
      is an ‘out of hours’ pharmacy which is open evenings, weekends and Bank Holidays; it is
      located in Warrington town centre and is thus readily accessible.

  •   ‘Locally Commissioned Services’ (i.e. services not commissioned by NHS England) are
      delivered by many pharmacies throughout the borough. The pharmacies delivering these
      services are, in the main, located in the areas of highest need. However there are
      opportunities for all pharmacies to further develop provision to support the improvement
      of population health and wellbeing. This will help ensure that the needs of specific localities
      are met in an accessible and cost-effective manner which further utilises the skills and
      expertise of community pharmacists.

  •   171 members of the public responded to the public survey. Overall, there was much
      positive feedback, especially regarding customer service, advice from pharmacists, and the
      facility to have pharmacies collecting prescriptions from GPs. Issues highlighted by some
      respondents related to the opening hours of their usual local pharmacy, communication
      about provision, and lack of privacy during consultations.

  •   This version of the PNA reflects the number of pharmacies in existence as at 1st February
      2018. This differs from the number included in the draft of the document that was available
      for statutory consultation between 10th November 2017 and 9th January 2018. This is due to
      the closure of a pharmacy in Great Sankey and Whittle Hall ward on 31st January 2018.

Recommendations

  •   Provision and Accessibility: The number of pharmacies across Warrington as a whole is
      adequate. However provision per head of population varies by neighbourhood. Warrington
      is a growing town and thus there will be a need for regular review to ensure that service
      provision continues to be in line with population growth, levels of need, and service
      configuration across different areas of the borough, with NHSE working, wherever possible,
      with existing contractors to ensure appropriate distribution and accessibility of services.

  •   Communication: To work with commissioners and pharmacy contactors to improve
      advertising of available pharmacy services and opening hours.

  •   Development of Services: To work with local pharmacies to further explore the potential
      offered to improve health and wellbeing and reduce health inequalities.

                                                                                                -5-
Regulatory Statements

The NHS (Pharmaceutical Services and Local Pharmaceutical Services) Regulation 2013 set out the
legislative basis for developing and updating PNAs and can be found at:
http://www.dh.gov.uk/health/2013/02/pharmaceutical-services-regulations/

Schedule 1 sets out the minimum information to be contained in pharmaceutical needs
assessments. Detailed below are the six statements included in schedule 1.

Statement 1:

A statement of the pharmaceutical services that the Health and Wellbeing Board (HWB) has
identified as services that are provided-
   (a) In the area of the HWB and which are necessary to meet the need for pharmaceutical
        services in its area; and
   (b) Outside the area of the HWB but which nevertheless contribute towards meeting the
        need for pharmaceutical services in its area (if the HWB has identified such services).
There is adequate provision of community pharmacy services. Warrington has 42 community pharmacy
contractors (one of which is also contracted by NHS England to provide the Local Pharmaceutical Services
(LPS) ‘Out of Hours’ service). There are also two Distance Selling contractors. Together these contractors
serve a total resident population of over 208,800 1. This equates to approximately one community pharmacy
for every 4,970 residents, compared to the England average of one pharmacy for every 4,600 residents.

Statement 2:

A statement of the pharmaceutical services that the HWB has identified (if it has) as services that
are not provided in the area of the HWB but which is satisfied-
    (a) Need to be provided (whether or not they are located in the area of the HWB) in order to
        meet a current need for pharmaceutical services, or pharmaceutical services of a
        specified type, in its area;
    (b) Will, in specified future circumstances, need to be provided (whether or not they are
        located in the area of the HWB) in order to meet a future need for pharmaceutical
        services, or pharmaceutical services of a specified type, in its area.
Current provision for areas across Warrington as a whole is adequate. No gaps in the provision of essential
pharmaceutical services have been identified in this PNA. Warrington is a growing town, with on-going
development anticipated over the lifetime of this PNA. It is anticipated that capacity within existing services
should be able to support the pharmaceutical needs of future populations of overall, however there will be a
need for regular review to ensure provision is equitably distributed in light of development.

1
    The GP Registered population is higher – currently approximately 215,000

                                                                                                          -6-
Some geographical differences in provision have been highlighted through this PNA. In-keeping with the
national picture, services are predominantly situated in more densely populated areas of the town. Thus,
more rural neighbourhoods such as the East ward grouping, have fewer pharmacies per head of population.
No pharmacies in the East ward grouping currently deliver a 100 hour contract, although there is some
evening and weekend provision.

Statement 3:

A statement of the pharmaceutical services that the HWB has identified (if it has) as services that
are provided-
    (a) In the area of the HWB and which, although they are not necessary to meet the need for
        pharmaceutical services in its area, nevertheless have secured improvements, or better
        access to pharmaceutical services in its area;
    (b) Outside the area of the HWB and which, although they do not contribute towards
        meeting the need for pharmaceutical services in its area, nevertheless have secured
        improvements, or better access to pharmaceutical services in its area;
    (c) In or outside the area of the HWB and, whilst not being services of the types described in
        sub-paragraph (a) or (b), or paragraph 1, they nevertheless affect the assessment by the
        HWB of the need for pharmaceutical services in its area.
This PNA has included an assessment of current need and service provision and has concluded that access to
pharmaceutical services is adequate for the current population. Residents of many of the more rural areas,
particularly around the border of Warrington, might also choose to use the services available in pharmacies
in neighbouring local authorities.

Statement 4:

A statement of the pharmaceutical services that the HWB has identified (if it has) as services that
are not provided in the area of the HWB but which the HWB is satisfied-
    (a) Would, if they were provided (whether or not they were located in the area of the HWB),
        secure improvements or better access to pharmaceutical services or pharmaceutical
        services of a specific type, in its area,
    (b) Would, if in specified future circumstances they were provided (whether or not they were
        located in the area of the HWB) secure future improvements or better access to
        pharmaceutical services or pharmaceutical services or a specified type in its’ area.
This PNA has included an assessment of current need and service provision, and has concluded that access
to pharmaceutical services is adequate for the current population. However, the skills and expertise of
community pharmacists could be further utilised in the provision of locally commissioned services aimed at
improving population health. Assessment of future plans for housing development within Warrington has
highlighted potential growth across all of the 4 ward groupings. It is envisaged that capacity within existing
services overall will be able to absorb the increased demand anticipated over lifespan of this PNA, however
regular review will be needed to ensure equitable distribution of provision in light of population growth.

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Statement 5:

A statement of any NHS services provided or arranged by the HWB, NHS Commissioning Board
(NHSCB) 2, a Clinical Commissioning Group (CCG), an NHS trust or an NHS foundation trust to
which the HWB has had regard in its assessment, which affect-
    (a) The need for pharmaceutical services, or pharmaceutical services of a specified type, in its
        area; or
    (b) Whether further provision of pharmaceutical services in its area would secure
        improvements, or better access to pharmaceutical services, or pharmaceutical services of
        a specific type in its area.
This PNA provides an overview of services commissioned locally to improve population health. This PNA has
identified that there are opportunities to further develop and extend the delivery of some of these services
within pharmacies, particularly needle exchange and some sexual health services.

Statement 6:

An explanation of how the assessment has been carried out, in particular-
   (a) How it has determined what are the localities in its area;
   (b) How it has taken into account (where applicable)-
       (i)    The different needs of different localities in its area, and
       (ii)   The different needs of people in its area who share a protected characteristic; and
   (c) A report on the consultation that it has undertaken.
The boundary of Warrington Borough Council is coterminous with that of Warrington Clinical Commissioning
Group (CCG), and this is also the area covered by Warrington Health and Wellbeing Board. Warrington has
22 electoral wards. Much of the data in this PNA has been calculated and mapped at ward level in order to
show the variations in health and lifestyle between smaller areas of the borough. Data in Warrington’s Joint
Strategic Needs Assessment (JSNA) is also often presented at ward level, and can therefore be used as a
supporting document. However, when detailing the services that pharmacies provide, it is impractical to
group them at such a small level of geography. Instead, wards have been allocated to one of four larger
ward groupings: Central wards – comprising the six wards in the centre of Warrington, (these wards roughly
approximate to the Central Area Neighbourhood Renewal locality, which is the geographical focus for
targeted interventions and regeneration to address health inequalities). The remaining wards have been
grouped into South, West and East localities. Aggregation at this level better reflects the areas that
customers are likely to travel to in order to access a pharmacy, especially residents of more rural areas.
Warrington town centre lies within the Central ward grouping.

2
    Following publication of the Regulations, the NHS Commissioning Board was renamed NHS England (NHSE)

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Contents

                                                                                                       Page
         Executive summary                                                                            4
         Regulatory statements                                                                        6

Part 1   Purpose, process, and explanation of pharmaceutical services                                 11
         Introduction and purpose                                                                     12
         Scope of the PNA                                                                             13
         Methodology and process followed in developing the PNA                                       13
         PNA consultation                                                                             15
         PNA Review process                                                                           16
         How to use this PNA document                                                                 16
         Setting the scene – national pharmaceutical services contract overview                       16
           • Essential services / prescription volume
           • Advanced services
           • Locally commissioned services
           • Funding of the pharmacy contract
         Overview of current providers of pharmaceutical services                                     20
           • Community pharmacy contractors
           • Dispensing doctors
           • Appliance contractors
           • Essential small pharmacy local pharmaceutical services
           • Local pharmaceutical services
           • Acute hospital pharmacy services
           • Mental health pharmacy services
           • GP Out of Hours services
           • Bordering services / neighbouring providers
         Quality Standards for pharmaceutical service providers                                       22
           • Pharmacy Contract Monitoring
           • Dispensing Services Quality Scheme

Part 2   Public health needs based on demography, localities and linked to JSNA                       23
         2.1) Geographical localities: wards and ward groupings                                       24
         2.2) Socio-economic deprivation                                                              26
         2.3) Population                                                                              29
         2.4) Health-related behaviour, lifestyle risk factors, and health conditions                 31
           • 2.4a) Obesity
           • 2.4b) Smoking
           • 2.4c) Alcohol
           • 2.4d) Other lifestyle risk factors (diet, physical activity, multiple lifestyle risks)
           • 2.4e) Substance misuse
           • 2.4f) Sexual health
           • 2.4g) Teenage conceptions
           • 2.4h) Long-term conditions
           • 2.4i) Older people (dementia, flu vaccinations, end of life and palliative care)
           • Table 2.9: list of Health indicators by ward and ward grouping
         2.5) Housing developments                                                                    49

                                                                                                              -9-
Part 3   Current service provision and future pharmaceutical service development and 51
         commissioning intentions
         3.1) Service development and future commissioning                           52
           • Introduction
           • Map 3.1 Location of pharmacies in Warrington
           • Table 3.1 List of pharmacies in Warrington
           • Map 3.2 Location of pharmacies in Warrington and surrounding areas
           • Map 3.3 Location of GP practices in Warrington
           • Table 3.2 List of GP practices with Wards and GP Clusters
         3.2) Provision and future development within Warrington ward groupings      58
           • 3.2a) Central ward grouping
           • 3.2b) East ward grouping
           • 3.2c) South ward grouping
           • 3.2d) West ward grouping
         3.3) Quality of provision: customer feedback                                61
           • 3.3 (a) Public Survey - Methodology
           • 3.3 (b) Public Survey - Profile of respondents
           • 3.3 (c) Public Survey - Pharmacy use
           • 3.3 (d) Healthwatch Intelligence on public experience of pharmacies
         3.4) Premises and general accessibility                                     64
         3.5) Advanced services                                                      65
         3.6) Locally commissioned services to meet health need                      65
         3.7) Recommendations for service development and future commissioning       66
         3.8) Service commissioning                                                  67
         3.9) Conclusion                                                             67

Part 4   Appendices
         Appendix 1: Policy context                                                 69
         Appendix 2: Acronyms, abbreviations and glossary of terms                  72
         Appendix 3: Pharmacy opening hours and services                            74
         Appendix 4: Prescribing data by pharmacy and GP Practice and GP Cluster    79
         Appendix 5: Public survey on pharmacy use                                  85
         Appendix 6: Formal consultation process, consultation questionnaire, and   88
         responses to questionnaire with resulting amendments
         Appendix 7: Additional amendments                                          92
         Appendix 8: References                                                     93

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Pharmaceutical Needs
            Assessment

                        Part 1
Purpose, Process, and Explanation of Pharmaceutical Services

                                                          - 11 -
Part 1

Introduction and Purpose

The effective commissioning of accessible primary care services is central to improving quality and
implementing the vision for health and healthcare. Community pharmacy is one of the most accessible
healthcare settings. Nationally, 99% of the population, including those living in the most deprived areas, can
get to a pharmacy within 20 minutes by car. In the most deprived areas, 96% of people have access to a
pharmacy either through walking or via public transport 3.

The Pharmaceutical Needs Assessment (PNA) presents a picture of community pharmacies and other
providers of pharmaceutical services, reviewing services currently provided and how these could be utilised
further. Community pharmacies can support the health and wellbeing of the population of Warrington, in
partnership with other community services and GP practices. Services can be directed towards addressing
health inequalities and supporting self-care in the areas of greatest need. Therefore, mapping service
provision and identifying gaps in demand or provision are essential to provide commissioners with the
market intelligence they need to take forward appropriate and cost-effective commissioning of services.

The Health Act 2009 outlined the process of market entry onto a ’Pharmaceutical List', by means of PNAs,
and provided information to Primary Care Trusts (PCTs) for their production. It amended the National Health
Service Act 2006 to include provisions for regulations to set out the minimum standards for PNAs. The
regulations came into force on 24 May 2010, requiring PCTs to:

       •    develop and publish PNAs
       •    use PNAs as the basis for determining market entry to NHS pharmaceutical services provision.

Following the abolition of PCTs, this statutory responsibility was passed to Health and Wellbeing Boards
(HWBs) by virtue of the National Health Service (Pharmaceutical and Local Pharmaceutical Services)
Regulations 2013, which came into force on 1st April 2013. These regulations also outline the process that
NHS England must comply with in dealing with applications for new pharmacies or changes to existing
pharmacies.

The Health and Social Care Act 2012 further describes the duty of commissioners, in accordance with the
regulations, to arrange for the adequate provision and commissioning of pharmaceutical services for their
population.

The PNA is thus a key tool for NHS England and local commissioners, to support the decision making process
for pharmacy applications and to ensure that commissioning intentions for services that could be delivered
via community pharmacies, in addition to other providers, are incorporated into local planning cycles. Local
commissioning priorities need to be driven by the Joint Strategic Needs Assessment (JSNA), of which the
PNA is a key component.

See Appendix 1 for policy context.

3
    DH (2008) Pharmacy in England: Building on strengths – delivering the future

                                                                                                           - 12 -
Scope of the PNA

The assessment of need addresses the following principles:

   • The safe and efficient supply of medicines, for example the additional (non-NHS commissioned)
     support services provided by pharmacies for:
           o their housebound patients and older people,
           o people with learning difficulties, and
           o medication administration support, such as monitored dosage systems (MDS)
   • Pharmaceutical care that supports safe and effective use of medicines
   • Pharmaceutical care that provides quality healthcare and public health information and advice to all
     members of the population
   • High quality pharmacy premises that increase capacity and improve access to primary care services
     and medicines
   • Enhanced services which increase access, choice and support for self-care
   • Locally commissioned pharmaceutical services that have the potential to reduce impact on GP
     practices and secondary care
   • High quality pharmaceutical support to prescribers for clinical and cost-effective use of resources.

Methodology and process followed in developing the PNA

Key principles of the PNA are:
    • It is an iterative process involving patients, the public and key stakeholders
    • It focuses on identifying health needs which can be supported by pharmaceutical services and
        makes recommendations for the commissioning of those services

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Development of Warrington HWB’s PNA has been undertaken by a small working group and overseen by
Warrington Joint Strategic Needs Assessment (JSNA) Steering Group. The working group consists of
representatives from the following:

       •   Public Health (Warrington Borough Council)
       •   Community Pharmacy Professional Lead (Community Pharmacy Cheshire and Wirral)
       •   NHS England local area team
       •   Healthwatch Warrington
       •   Warrington CCG
       •   Communications Team, WBC

Aspects informing this PNA were undertaken on a Cheshire & Merseyside level, and acknowledgments are
also due to Liverpool City Council for administering the public survey and Halton Borough Council for leading
on the evidence base.

The content of the document is closely linked to the local JSNA and has been produced by means of a
structured analysis and distillation of complex and comprehensive data sources in order to identify the
following:

   • current local provision of pharmaceutical services
   • the health and pharmaceutical needs of the population
   • gaps in provision of pharmaceutical services.

A range of data sources have been used for the purposes of this PNA, including, but not restricted to:

   •   Joint Strategic Needs Assessment
   •   Public Health Annual Report
   •   Office of National Statistics data
   •   Warrington Health and Wellbeing Survey 2013
   •   Public survey on experience and opinion of local pharmacy services
   •   Survey of local pharmacists

A formal 60 day public consultation was undertaken on the draft PNA, and relevant amendments have been
made to it in order to produce this final publication. Responses to the consultation and the associated
amendments where relevant are listed in Appendix 6.

                                                                                                         - 14 -
PNA Consultation

A     draft    PNA       was    published     on      the    Warrington Borough     Council    website
https://warrington.gov.uk/consultations on 10th November 2017. Various stakeholders were notified and
invited to take part in the consultation which closed on 9th January 2018. The survey questions for the
consultation are listed in Appendix 6. Stakeholders include:

   •   Dispensing Doctors
   •   GPs and other Primary Care Staff
   •   Community pharmacists
   •   LPS pharmacy contractor
   •   Bridgewater Community Health Trust
   •   North West Boroughs Partnership Mental Health Trust
   •   Warrington and Halton Hospitals Foundation Trust (WHHFT)
   •   Local Pharmaceutical Committee (LPC)
   •   Local Medical Committee (LMC)
   •   Local hospices
   •   Public Health staff
   •   NHS England staff
   •   Warrington Clinical Commissioning Group (CCG)
   •   Neighbouring Health and Wellbeing Boards (HWBs)
   •   Healthwatch Warrington

Website and online survey

Full documentation was published on the Warrington Borough Council website on 10th November 2017 with
an online survey facility to enable readers to make comments on the PNA. Respondents were also offered
paper copies of the survey if required and freepost systems were available to ensure people were able to
make their views known.

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PNA Review Process

The PNA will be refreshed, or supplementary statements produced, when any changes to the pharmacy
contractor list occurs. This action will be overseen by Warrington HWB, with input from NHS England. The
PNA will be updated or added to via supplementary statements should any of the following occur:

    •   New pharmacy contracts
    •   Pharmacy closures
    •   Pharmacies merge or consolidate
    •   Changes to pharmacy locations
    •   Changes to pharmacy opening hours
    •   Local intelligence and significant issues relating to pharmacy enhanced service provision
    •   Appliance provision changes
    •   Significant changes in public health intelligence or primary care service developments that may impact
        either beneficially or adversely on pharmacy-based services.

How to use this Pharmaceutical Needs Assessment

The PNA should be utilised as a service development tool in conjunction with the Joint Strategic Needs
Assessment (JSNA) and the strategic plans from local commissioners. Mapping out current services and
gaining a sense of current and future service needs will pinpoint the areas where the development of local
pharmaceutical services may be necessary.

The PNA can be used by patients, current service providers, future service providers and commissioners in
the following ways:

        •   Maps and tables detailing specific services will mean patients can see clearly where they can access
            a particular service.
        •   Current service providers will be better able to understand the unmet needs of patients in their area
            and take steps to address this need.
        •   Future service providers will be able to tailor their applications to be added to the pharmaceutical
            list, to ensure that they provide the services most needed by the local community.
        •   Commissioners will be able to move away from the ‘one-size fits all’ approach to ensure that
            pharmaceutical services are delivered in a targeted way.
        •   NHS England will have information on existing provision and on the needs of local populations to
            help assess new applications to join the pharmaceutical list, in order to ensure that patients receive
            quality services and adequate access.

Setting the Scene – National Pharmaceutical Services Contract Overview

All national NHS pharmaceutical service providers must comply with the contractual framework that came
into force on 1st April 2013. The national framework is set out below and can be found in greater detail on
the PSNC website 4:
The pharmaceutical services contract consists of three different levels:
             • Essential services
             • Advanced services
             • Enhanced services

4
    Pharmacy Services Negotiating Committee: http://psnc.org.uk/services-commissioning/

                                                                                                            - 16 -
Essential services

The following services must be offered by all community pharmacy contractors:

Dispensing - Supply of medicines or appliances, advice given to the patient about the medicines being
dispensed and advice about possible interactions with other medicines. Also, the recording of all medicines
dispensed, significant advice provided, referrals and interventions made using a Patient Medication Record.

Prescriptions - During 2016/17, the 28 GP practices in Warrington issued a total of 3,802,681 individual
prescription items. Of these, 94% (3,576,033) were dispensed by the 47 pharmacies located at that time
within Warrington (including the 2 internet pharmacies, the Out of Hours pharmacy, and the 2 community
pharmacies which have since closed 5), 0.8% (28,665) by the one dispensing doctor in Warrington (Stretton
Medical Centre), and 5.2% (197,983) were dispensed outside Warrington. The 3,576,033 items dispensed by
the 46 pharmacies in Warrington gave an average of 77,739 items per pharmacy. Appendix 4 shows the
number and proportion of items prescribed at each GP practice and dispensed by each pharmacy. It also
shows this data by GP cluster 6.

Table 1.1: Items prescribed by Warrington Practices 2016/17 by dispenser
                                                        Number of items                           Percentage of
Dispensed by
                                                            dispensed                           items dispensed
Warrington pharmacies (including 44 community, 2
                                                                                                              94.0%
internet pharmacies and the Out of Hours pharmacy)                3,576,033
Dispensing doctor (Stretton Medical Centre)                                                                    0.8%
                                                                                    28,665
Outside Warrington                                                                                             5.2%
                                                                                  197,983
Total                                                                           3,802,681                  100.00%
Data source: NHS Business Services Authority

Repeat dispensing - Management of repeat medication for up to one year, in partnership with the patient
and prescriber. The patient will return to the pharmacy for repeat supplies, without first having to visit the
GP surgery. Before each supply, the pharmacy will ascertain the patient’s need for a repeat supply of a
particular medicine. The pharmacist will communicate all significant issues to the prescriber with
suggestions on medication changes, as appropriate.

Disposal of unwanted medicines – Pharmacies act as collection points for returned unwanted medicines
from households and individuals. Special arrangements apply to Controlled Drugs (post Shipman Inquiry)
and private arrangements must be adopted for waste returned from nursing homes.

Promotion of healthy lifestyles (Public Health) - Opportunistic one to one advice provided on healthy
lifestyle topics such as smoking cessation, weight management etc., to certain patient groups who present
prescriptions for dispensing. Also, involvement in local public health campaigns organised by NHS England
and by Public Health on behalf of the HWB.

Signposting patients to other health care providers - Pharmacists and their staff will refer patients to other
healthcare professionals or care providers when appropriate.

5
    Two pharmacies closed since 2016/17 data; Rowlands (Wilderspool Causeway) and the Hub Pharmacy (Barrowhall Lane).
6
    GP practices in Warrington work together in 7 clusters to optimise the delivery of primary care services.

                                                                                                                        - 17 -
Support for self-care - The provision of advice and support by pharmacy staff to enable patients to derive
maximum benefit from caring for themselves or their families. It will initially focus on self-limiting illness,
but support for people with long-term conditions is also a feature of the service.

Clinical Governance – Pharmacists must ensure the following processes are in place:
    • Use of standard operating procedures
    • Patient safety incident reporting
    • Demonstrating evidence of pharmacist Continuing Professional Development
    • Operating a complaints procedure
    • Compliance with Health and Safety legislation
    • Compliance with the Disability Discrimination Act 1995 (now superseded by the Equality Act 2010)
    • Significant event analysis
    • Commitment to staff training, management and appraisals
    • Undertaking patient satisfaction surveys

Advanced services

There are currently six advanced services 7 within the NHS Community Pharmacy contract. Community
pharmacies can opt to provide any of these services as long as they meet the requirements set out in the
Secretary of State Directions.

1. Medicines Use Review (MUR) The pharmacist conducts a concordance medication review with the
patient, whereby the patient’s knowledge of their medication regime is assessed. The review assesses any
problems with understanding current medication, its administration and patient compliance. During the
course of the MUR, if the pharmacist thinks there are issues the GP should be aware of, a report is provided
to the patient’s GP. The patient’s knowledge of their medication and why they are taking it is increased, and
problems with their medication are identified and addressed. The service includes MURs undertaken
periodically, i.e. where the MUR is conducted on a regular basis, for example, every 12 months, and MURs
undertaken when the need to make an adherence-focussed intervention is identified during provision of the
dispensing service. MURs must be conducted in a consultation area which ensures patient confidentiality
and privacy. Pharmacists must successfully pass a competency assessment before they can provide MUR
services.

2. Appliance Use Review (AUR) – An Appliance Use Review was the second advanced service, introduced in
April 2010. This service is similar to that above, but relates to a patient’s prescribed appliances such as leg
bags, catheters and stoma products.

3. Stoma appliance customisation (SAC) service
Stoma appliance customisation was the third advanced service, introduced in April 2010. This service
involves the customisation of stoma appliances, based on the patient’s measurements or on a template.
The aim of the service is to ensure proper use and comfortable fitting of the stoma appliance and to improve
how long they are used for, thereby reducing waste and unnecessary patient discomfort. This service can be
provided by either pharmacy or appliance contractors.

4. New Medicines Service (NMS) – This service was introduced in October 2011 and provides support with
medicines adherence for patients being treated with new medicines in four conditions/therapy areas. These
are: asthma/COPD, type 2 diabetes, hypertension, and antiplatelet/anticoagulation therapy. The pharmacist
provides face-to-face counselling about the medicine when the patient first presents with their prescription
at the pharmacy. Arrangements are then made for the patient to be seen 7-14 days later to assess

7
 Pharmaceutical Service Negotiating Committee (PSNC) accessed from http://psnc.org.uk/services-
commissioning/advanced-services/

                                                                                                         - 18 -
adherence and discuss any problems with the new medicine. The patient is followed up 14 days later to
check all is well, at which point they exit this service.

5. Community Pharmacy Seasonal Influenza Vaccination Programme As part of the community pharmacy
funding settlement community pharmacies in England are now able to offer a seasonal influenza (flu)
vaccination service for all adults at risk of developing more serious complications from the virus. These
include people aged 65 years and over, pregnant women and those with certain health conditions. This
service is the fifth Advanced Service in the English Community Pharmacy Contractual Framework (CPCF).
Immunisation is one of the most successful and cost-effective health protection interventions and is a
cornerstone of public health. High immunisation rates are key to preventing the spread of infectious disease,
complications and possible early death among individuals and protecting the population’s health. For most
healthy people, influenza is an unpleasant but usually self-limiting disease. However those with underlying
disease are at particular risk of severe illness if they catch it. The aim of the seasonal influenza vaccination
programme is to protect adults and children who are most at risk of serious illness or death should they
develop influenza, by offering protection against the most prevalent strains of influenza virus.

The service can be provided for adults by any community pharmacy in England that fully meets the
requirements for provision of the service and has notified NHS England of their intention to begin providing
the service by completing a notification form on the NHS BSA website.

6. NHS Urgent Medicine Supply Advanced Service (NUMSAS) From 1st December 2016, community
pharmacies across England have been able to register on the NHS Business Services Authority (BSA) portal to
provide the NHS Urgent Medicines Supply Advanced Service (NUMSAS) as part of a national pilot. The
Service, which is commissioned by NHS England, will allow community pharmacies to supply a repeat
medicine at NHS expense, following a referral from NHS111 and where the pharmacist identifies that the
patient has an immediate need for the medicine and that it is impractical to obtain a prescription without
undue delay.

Enhanced services

Enhanced services are those pharmacy services commissioned on behalf of the NHS by NHS England.
Enhanced services can only be commissioned by NHS England.

Locally commissioned services

Locally commissioned services are those developed and negotiated locally based on the needs of the local
population. The PNA will inform the future commissioning need for these services. These services can be
commissioned from the pharmacy by the Local Authority (LA), Clinical Commissioning Group (CCG) or other
commissioner. Competency and training frameworks to support the commissioners of such services are
available from the Centre for Pharmacy Postgraduate Education (CPPE) 8. Likewise, the Pharmacy and Public
Health Forum which now reports to Public Health England has a task group responsible for professional
standards for public health practice.

It is possible for neighbouring LAs and CCGs to commission similar services from pharmacies at differing
remuneration rates or using different service specifications or patient group directions. This is because
financial and/or commissioning arrangements for services are based on local negotiation and are dependent
on available resources. This does, however, lead to duplication of effort for commissioning staff and
difficulties for locum pharmacists working across LA and CCG boundaries. Wherever possible, commissioners
are advised to work together to eliminate such anomalies.

8
    www.ccpe.ac.uk

                                                                                                         - 19 -
The continuity of locally commissioned service provision has often been difficult to achieve. There have been
on-going challenges around pharmacists gaining accreditation to deliver those services and individual
pharmacists/locums who were accredited to provide these services may move around. This has had the
potential to lead to gaps in services. Some work has been undertaken by the Community Pharmacy
Competence Group (CPCG) to allow pharmacy professionals to be able to declare their own competence to
deliver locally commissioned community pharmacy services, via self-Declaration of Competence documents
(DoCs). This self-declaration process provides assurance that pharmacy professionals are competent to
provide a service while minimising bureaucracy. The requirement for self-declaration is included within local
contracts for locally commissioned services, and pharmacists who fail to meet this requirement will be
removed from the Warrington Borough Council provider list.

Examples of some pharmacy-based locally commissioned services are as follows:
    • Minor ailment management
    • Diabetes screening
    • Substance misuse medication services / Needle exchange scheme
    • Palliative care services
    • Emergency Hormonal Contraception service / Sexual health services
    • Vascular screening
    • Care home services
    • Smoking cessation service
    • Flu vaccination services

Funding of the service elements of the pharmacy contract

The essential services and the advanced services elements of the community pharmacy contract are funded
from a national ‘Pharmacy Global Sum’ agreed between the Pharmaceutical Services Negotiating
Committee, NHS England and NHS employers. This is divided up and devolved to NHS England as a cash-
limited budget which is then used to reimburse pharmaceutical service activity as per the Drug Tariff
(Surelines Ltd: Drug Tariff Listing Service www.drugtariff.com) Funding for enhanced or locally
commissioned services has to be identified and negotiated locally from the commissioner’s own budget.

Overview of current providers of pharmaceutical services

At February 2018, Warrington has 45 pharmacy contractors on the pharmaceutical list:
    • 42 are community pharmacies; 37 of which deliver a minimum of 40 core service hours per week,
        although many open for longer, and 5 deliver a minimum of 100 hours service per week
    • 1 is the LPS ‘out of hours’ (OOH) pharmacy (located at one of the community pharmacies)
    • 2 are distance selling (internet) pharmacies.

Map 3.1 in Part 3 shows the location of pharmacy service providers.

Community pharmacy contractors can be individuals who independently own one or two pharmacies, or
can be large multi-national companies who may own many hundreds of pharmacies UK-wide.

The resident population of the Warrington is 208,800 (ONS mid-2016) 9 which equates to 20.1 community
pharmacies per 100,000 population. The average for England is 21.5 pharmacies per 100,000 population.

9
 ONS Mid-Year Estimates 2016 for Local Authorities. Sub-borough estimates for 2016 are not yet available. Ward
estimates presented for the new ward boundaries are based on internal calculations using Mid 2015 LSOA level
estimates

                                                                                                             - 20 -
Whilst this is a crude comparator in that it does not take account of geographical spread or accessibility, it
does suggest that, overall, provision in Warrington is slightly lower than the average for England.

In general, pharmacy services are provided free of charge, without an appointment, on a ’walk-in’ basis.
Pharmacists dispense medicines and appliances, as requested by prescribers, via both NHS and private
prescriptions.

Dispensing Doctors – Warrington has one dispensing doctor whose services consist mainly of dispensing for
those patients on their “dispensing list”, who live in more remote, rural areas. There are strict regulations
which stipulate when, and to whom, doctors can dispense. Dispensing practices do not offer as
comprehensive a range of medication-related services as community pharmacists. It is not a requirement for
dispensing practices to employ a qualified pharmacist, although they could choose to do so.

Appliance Contractors cannot supply medicines but are able to supply products such as dressings, stoma
bags, catheters etc. Currently, Warrington does not have an appliance contractor physically located within
its area, but patients can access services from appliance contractors registered in other areas.

Acute Hospital Pharmacy Services - There is one acute hospital trust within Warrington, namely Warrington
and Halton Hospitals NHS Foundation Trust. Hospital Trusts have Pharmacy Departments, the main
responsibility of which is to dispense medications for use on the hospital wards for in-patients and during
the out-patient clinics.

Mental Health Pharmacy Services - The population of Warrington is served by the North West Boroughs
Healthcare NHS Foundation Trust. They employ pharmacists to provide clinical advice within their specialist
areas and have a pharmacy department that dispenses medications for use on the hospital wards for in-
patients and during the out-patient clinics.

GP Out of Hours (OOH) Services– The GP OOH service in Warrington operates Monday to Friday 6:30pm to
8:00am and 24 hours weekends and Public Holidays for patients who feel their illness cannot wait until their
GP surgery re-opens. Appointments are held at the OOH located at Bath Street Health and Wellbeing Centre
in Warrington town centre.

Local Pharmaceutical Services (LPS) - OOH pharmacy: the LPS pharmacy contract is a time-limited contract
which allows commissioners to contract locally for the provision of pharmaceutical and other services,
including services not traditionally associated with pharmacy, within a single contract. Given different local
priorities, LPS provides commissioners with the flexibility to review the contract periodically and to
commission services that address specific local needs, which may include services not covered by the
community pharmacy contractual framework. There is currently one LPS contract in Warrington that was
established in 2004 to support the Out of Hours GP service (located at Bath Street Health and Wellbeing
Centre in Warrington town centre) and to provide access to emergency medication for patients requiring it
at the point of prescribing. The pharmacy is open 6:30pm to 10:30pm Monday to Wednesday, 6:30pm to
10:45pm Thursday and Friday, 12:15pm to 10:45pm on Saturday, and 09:30am to 10:30pm Sunday. It is also
open on Bank Holidays. Patients attending the GP OOH service, who subsequently require a medicine to be
dispensed, are provided with a prescription to take to any local community pharmacy, or to the OOH
pharmacy on-site.

Bordering Services / Neighbouring Providers
The population of Warrington can access services from pharmaceutical providers located outside the Local
Authority’s own boundary. When considering pharmacy contract applications or making enhanced service
commissioning decisions, the accessibility of services close to the border must be taken into account. For
further information on such services please refer to the relevant neighbouring Health and Wellbeing Board’s
PNA.

                                                                                                        - 21 -
Quality Standards for Pharmaceutical Service Providers

Community Pharmacy Contract Monitoring
NHS England requires all pharmaceutical service providers to meet the high standards expected by patients
and the public. All pharmacies are included within a programme of contract monitoring visits as
independent providers of services provided under the national pharmacy contract.

As stated within the NHS review 2008, high quality care should be as safe and effective as possible, with
patients treated with compassion, dignity and respect. As well as clinical quality and safety, quality means
care that is personal to each individual. This statement is as meaningful to pharmacies as to other NHS
service providers and is the principle which NHS England adopts when carrying out the Community
Pharmacy Contract Monitoring visits.

The community pharmacy contract assurance process follows a structured sequence of events including:
    • A rolling programme of pre-arranged visits to pharmacies for observation of processes and
       procedures and a detailed interview with the pharmacist in charge and support staff.
    • Self-assessment declarations
    • Scrutiny of payment submission processes
    • Scrutiny of internal processes for confidential data management
    • Structured action plan with set timescales for completion

In addition to the structured process outlined above, NHS England will also take account of the voluntary
submission of the findings from the annual community pharmacy patient questionnaire that is undertaken
by the pharmacy contractor as well as any patient complaints relevant to pharmacy services. In cases where
the professional standards of an individual pharmacist are found to fall below the expected level, NHS
England will work with the relevant professional regulatory body, such as the General Pharmaceutical
Council to ensure appropriate steps are taken to protect the public.

The Dispensing Doctor Quality Scheme introduces defined quality markers for service delivery and sets
standards around governance and training. Its aim is to develop and ensure good/safe dispensing practice by
rewarding dispensing practices for providing high quality dispensing services by making a payment per
dispensing patient. Payment is based on an assessment of compliance against set standards and criteria.
Participation in the scheme is voluntary.

Locally Commissioned Services
Warrington Borough Council currently commission pharmacies to provide:
    • Emergency Hormonal Contraception (EHC)
    • Quick Start contraceptive services
    • Supervised Consumption of Methadone and Buprenorphine
    • Needle Exchange

Pharmacies providing or seeking to provide any of the above services need to complete a quality assurance
questionnaire, to ensure that the quality of the service recommended in the Service Level Agreement is
fulfilled, and best value is achieved. Pharmacists delivering the service must also complete all relevant
training to deliver these services and submit a self-declaration of competency, a signed contract and Patient
Group Direction (PGD) must be returned prior to service commencement. Services are monitored on a
regular basis using an assurance framework and quality visits are carried out at premises as required. For
provision of Needle Exchange services, an Integrated Monitoring System (IMS) is also used across Cheshire
and Merseyside. This enables prevalence, drug usage and demographics to be monitored and cross-
referenced with the invoice payment schedule, to provide a comprehensive overview of provision.

                                                                                                       - 22 -
Pharmaceutical Needs
                 Assessment

                                  Part 2
     Public Health needs based on demography, localities and
          linked to the Joint Strategic Needs Assessment

This section contains extracts from Warrington Health and Wellbeing Board’s Joint
Strategic Needs Assessment. These are areas where it is considered that pharmacy
services could, or already do, contribute to those needs. This information is taken
into account in Part 3 where the commissioning of pharmacy services is considered.
For more detailed information readers are requested to refer to the JSNA itself, at
https://www.warrington.gov.uk/jsna

                                                                              - 23 -
Part 2
2.1: Geographical Localities - Wards and Ward Groupings

The boundary of Warrington Borough Council is coterminous with that of Warrington Clinical Commissioning
Group (CCG), and this is the area covered by the Health and Wellbeing Board. The advantage of one Local
Authority (LA) and one CCG means that the mapping and consultation applies to the geographical footprint
of both organisations.

Warrington has 22 electoral wards which are displayed on Map 2.1. Much of the data in this PNA has been
calculated and mapped at ward level in order to show the variations in health and lifestyle between smaller
areas of the borough. Data in Warrington’s Joint Strategic Needs Assessment (JSNA) is also often presented
at ward level, and can therefore be used as a supporting document. However, when detailing the services
that pharmacies provide, it is impractical to group them at such a small level of geography. Instead,
pharmacies have been grouped as being in one of 4 ward groupings; this will better reflect the areas that
customers are likely to travel to in order to access a pharmacy, especially residents of more rural areas.
Warrington town centre lies within the group of Central wards. The ward groupings are as follows:

    •   Central wards: Bewsey & Whitecross, Fairfield & Howley, Latchford East, Latchford West, Orford,
        Poplars & Hulme
    •   East wards: Birchwood, Culcheth, Croft & Glazebury, Poulton North, Poulton South, Rixton &
        Woolston
    •   South wards: Appleton, Grappenhall, Lymm North & Thelwall, Lymm South, Stockton Heath
    •   West wards: Burtonwood & Winwick, Chapelford & Old Hall, Penketh & Cuerdley, Great Sankey
        North & Whittle Hall, Great Sankey South, Westbrook.

GP practices in Warrington work together in seven clusters to optimise the delivery of primary care services.
The tables in Appendix 4 help to illustrate patient flow by Cluster.

                                                                                                       - 24 -
Map 2.1: Ward Groupings used in the Warrington PNA

                                                     - 25 -
2.2: Socio-Economic Deprivation

Socio-economic deprivation is a major determinant of health and wellbeing. Many of the measures of ill-
health and health-related lifestyle factors follow patterns of socio-economic deprivation, with more ill-
health in the more deprived areas.

Deprivation covers a broad range of issues and refers to unmet needs caused by a lack of resources of all
kinds, not solely financial. The English Indices of Deprivation (Department for Communities and Local
Government, 2015) cover 7 ‘domains’; Income, Employment, Health and Disability, Education, Barriers to
Housing and Services, Crime, and Living Environment. The overall Index of Multiple Deprivation 2015 (IMD
2015) is calculated as a weighted aggregation of these seven domains. Full details of all of the domains and
the indicators they contain can be found in the full technical report produced on behalf of the DCLG:
https://www.gov.uk/government/collections/english-indices-of-deprivation

The lowest geographical level for which the indices are produced is at Lower Super Output Area (LSOA) level.
LSOAs are small geographical units, each of which has a minimum of 400 households and an average
population of approximately 1500 people. Warrington contains 127 LSOAs. These do not all neatly ‘nest’
inside the 22 electoral wards.

LSOAs can be grouped by ‘deprivation quintile’; all LSOAs in England were split into 5 equal-sized groups
(quintiles) based on levels of deprivation. Each LSOA in Warrington is allocated to a deprivation quintile
based on how deprived that LSOA is compared to the rest of England: Quintile 1 contains areas of
Warrington that are in the most deprived fifth in England, and Quintile 5 contains the areas in the least
deprived fifth. Map 2.2 shows levels of deprivation in Warrington. Table 2.1 shows the composition of the
four groups of wards in terms of the population and the number of LSOAs in each deprivation quintile.

Detailed analysis of the pattern of deprivation across Warrington is available in the Warrington JSNA at
http://www.warrington.gov.uk/jsna

                                                                                                           - 26 -
Map 2.2: Deprivation in Warrington - Index of Multiple Deprivation (IMD) 2015

Data source: Department of Communities and Local Government (DCLG), Indices of Deprivation 2015, © Crown Copyright.

                                                                                                                      - 27 -
Table 2.1: Ward Population in Each Deprivation Quintile

Data sources: ONS Census 2015 population estimates, DCLG Index of Multiple Deprivation 2015

Inequalities in relation to socio-economic deprivation within Warrington are quite stark. The majority of the
population of the East, South and West ward groupings live in quintiles 3, 4 and 5 (the 60% least deprived
areas in England). In particular, over three-quarters (78%) of the population in the South grouping live in
quintile 5 (the 20% least deprived areas in England). In contrast, over half of the population (55%) of the
Central grouping live in quintile 1, and over a third (36%) live in quintile 2; this means that 91% of residents
of the Central ward grouping live in the most deprived 40% of areas in England.

                                                                                                         - 28 -
2.3: Population

The resident population of Warrington for mid-year 2016 is estimated at 208,800. x The population of the
borough overall is increasing, with an increase of over 3% over the past five years. Resident population
estimates are available at LSOA level from the Office of National Statistics (ONS). These have been
aggregated to give population estimates for wards and ward groupings, and are shown in Table 2.2.

The GP registered population of Warrington is higher than the resident population; currently over 215,000. xi

Warrington has a relatively small, but growing, ethnic population. Based on the 2011 Census almost 92.9%
of Warrington residents were ‘White British’ xii.

Table 2.2: Warrington Wards Resident Population

Source: Internally calculated using Office for National Statistics LSOA population estimates for 2015.

x
   ONS 2016 Estimates for Local Authorities. Sub-borough estimates for 2016 are not yet available. Ward estimates presented for the
new ward boundaries are based on internal calculations using Mid 2015 LSOA level estimates
xi
    NHS Digital, Nov 2016
xii
    Includes: White Irish, Scottish, Welsh and English

                                                                                                                             - 29 -
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